CASE REPORT
Fracture of a Sound Tooth in a Pilot Under
Hypobaric Conditions
Mathieu Gunepin, Florence Derache,
and Thomas Audoual
GUNEPIN M, DERACHE F, AUDOUAL T. Fracture of a sound tooth in a
pilot under hypobaric conditions. Aviat Space Environ Med 2010;
81:691–3.
Dental fractures induced by changes in atmospheric pressure, called
odontocrexis, are described in aviation dentistry articles. According to
previous reports, these pathologies are induced exclusively in teeth with
defective dental restorations. Nevertheless, in this case report we de-
scribe a tooth fracture occurring on an apparently sound tooth in a
fighter pilot during a flight. All usual etiologies of this odontocrexis can
generally be eliminated. This atypical fracture shows that all pathophysi-
ology and contributing factors of odontocrexis are still widely unknown.
Keywords: odontocrexis, dental fracture, aviation dentistry, aircrew.
O DONTOCREXIS IN Greek means “tooth explo-
sion.” The term was first used in the aeronautical
environment by Calder and Ramsey (3), who described
such tooth fractures in aircrew due to changes in baro-
metric pressure. A similar term, odontoclasis, means
“tooth fracture.” This phenomenon often occurs in teeth
with large defective dental restorations, however, we
did not find any articles concerning a tooth fracture oc-
curring in a tooth with no pathology or dental treatment.
In December 2009, a fighter pilot presented to the den-
tal clinic at the French Military Medical-Surgical Hospi-
tal (HMC)* at Kaia (International Airport of Kabul) for
sensitivity to cold due to a tooth fractured during a
flight. Based on a radiograph taken in 2006, this tooth
was supposedly sound before the mission. This case re-
port shows that the physiopathology and the predispos-
ing factors of tooth fractures in hypobaric conditions are
still widely unknown.
Case Report
In December 2009, a fighter pilot presented for a
dental consultation at the HMC at Kaia for sensitivity to
cold in the right mandibular area. The patient stated that
he broke his tooth during a flight just before being de-
ployed to Afghanistan. The dental fracture occurred
when he was flying for about 90 min. The maximum al-
titude during the flight was 3600 m (12,000 ft). During
* The HMC at Kaia was established by NATO at the beginning of
2009. At the time of its inauguration in July 2009, it was placed under
French command (5). The HMC is manned by 125 military personnel
of 6 nationalities (French, Belgian, Portuguese, American, German,
and Bulgarian), of whom 91 are French. The HMC is responsible for
the medical support of all military and civilian personnel working for
NATO, the United Nations, nongovernmental organizations, NAMSA,
Afghan security forces, and the civilian population in the area.
Aviation, Space, and Environmental Medicine x Vol. 81, No. 7 x July 2010
the descent, near 900 m (3000 ft), the patient stated that
he felt his tooth “inflate” with an acute pain. Although
the pilot was not able to precisely describe the pain, he
asserted that it was not dull or like a pulse-beat. Since the
pain continued for about 1 min, the pilot felt that his tooth
had broken. Even though the pain was intense, it was so
brief that it did not adversely impact the mission.
During the dental exam, we noticed a fracture of the
tooth #30 (mandibular right first molar – FDI #46). This
fracture had the form of a “V” with the peak of the V in
the central pit (Fig. 1). Dental hard tissues were clean
and hard with no sign of dental decay. Several dental
tests were conducted.
Vitality test: A cotton pledget was exposed to an ice
spray (Cryospadw, Dentsply Caulk Inc., York, PA; boiling
point of Tetrafluoroethane: 215.54°F) and then the cot-
ton was placed on the tooth. The tooth responded to the
cold with a sharp pain within a few seconds. That sug-
gested that the tooth was vital.
Tenderness to percussion: When the tooth was gently
tapped with the handle of a mouth mirror no painful
response was elicited.
Temperature: There was no sensitivity to a hot stimu-
lus. Sensitivity to cold, the reason for the dental consul-
tation, was directly linked to the huge quantity of hard
tissue lost due to the fracture within the proximity of the
dental pulp. This was confirmed by radiograph (Fig. 2).
There was no spontaneous pain.
The full dental exam performed allowed us to show
that the patient had no odontological pathology and/or
treatment. We noted the absence of the four wisdom
teeth. The treatment of this broken tooth consisted of:
• Articaine local anesthesia (Articadentw 1/100,000; Dentsply
Caulk, Inc., York, PA) with intraseptal injection;
From the Military School of Artillery, Draguignan French Military
Health Service, Draguignan Cedex, France; the Military Hospital
Sainte Anne, Toulon French Military Health Service, Toulon Cedex,
France; and the Military Medical Center, Avord French Military Health
Service, Avord, France.
This manuscript was received for review in January 2010. It was
accepted for publication in March 2010.
Address correspondence and reprint requests to: Mathieu Gunepin,
D.D.S., Secteur Dentaire Interarmées de Draguignan, BP 400, 83007
Draguignan Cedex, France; mgunepin@yahoo.fr.
Reprint & Copyright © by the Aerospace Medical Association,
Alexandria, VA.
DOI: 10.3357/ASEM.2754.2010
691
ATYPICAL TOOTH FRACTURE—GUNEPIN ET AL.

thermal sensitivity, pulpitis, and possible occurrence of

barodontalgia (oral pain evoked by a change in baro-
metric pressure) (6,11,12). For our patient, a flight re-
striction (duty not involving flying – DNIF) of 8 h was
required due to the local anesthesia.

DISCUSSION
We would have expected such a fracture to occur dur-
ing the climb to 3600 m (12,000 ft) in a fighter aircraft
with a combat differential altitude cockpit. It was almost
counterintuitive that the event occurred during descent,
unless it was related to a high G force pull out from a
dive. In a review of the literature, it appears that tooth
fractures due to changes in barometric pressure are quite
rare and the current incidence rate of the phenomenon is
unknown. All of the odontocrexis events reviewed oc-
curred in teeth with predisposing factors (3,7). Compare
this fact with our case report:
• For our patient, the dental hard tissue loss cannot be due to the
loss of a pre-existent dental restoration. The angle at the peak of
the “V” was so acute that it could not have been negotiated by
most dental instruments. This was consistent with the fact that
our patient asserted that he did not have prior dental treatment
on this tooth. This was confirmed by a panoramic radiograph,
taken in 2006, located in his dental record in France. This radio-
graph also showed no visible evidence of dental decay at that
time (Fig. 3).
• The shape of the fracture area did not clinically resemble dental
decay. The dental hard tissue walls of the fracture site were
Fig. 1. Fracture (black line) of tooth #30 (mandibular right first mo-
sound.
lar): all views.
• The location of the fracture did not generally correspond to an area
of tooth weakness. Cusps can be subjected to transverse pressures,
which are deleterious. This is especially the case when someone
• Preparation of the cavity to receive the restoration material; unexpectedly interposes a hard element between the occlusal sur-
• Application of a protective cavity liner/base (Dycalw, Dentsply faces during mastication (for example: a shot pellet in game bird).
Caulk Inc., York, PA); and Such pressures can result in an instantaneous fracture of cusps. We
• Restoration with an amalgam (Nogama 2, R&S). recognize that the distal-buccal cusp of that tooth is generally the
weakest of the five cusps on that tooth. Our pilot’s cusps were in-
The treatment performed (technique, materials, etc.) tact and the loss of hard dental tissue was located in the occlusal
was consistent with the principles of aviation dentistry fissure of the tooth from the central pit to the distal surface.
described by Zadik and other authors (1,2,9,10), who • Some authors note that bruxism can involve a weakening of teeth
in aircrews (8). During the dental examination of our pilot, we
recommend specific care for aircrew. Even though no noticed the presence of wear facets on the teeth from premolars to
sign of decay was noticed, the cavity was curettaged/ premolars in both arches. When we asked the pilot about possible
prepared with care to prevent any carious lesion under- bruxism, he stated that he did grind his teeth during his training
neath the amalgam restoration. The application of a pro- from 2002 to 2004, but that he longer clenched or ground his teeth.
tective cavity liner was a preventive measure against

Fig. 2. Radiograph of tooth #30 (mandibular right first molar). Fig. 3. Panoramic radiograph taken in 2006 (D 5 right).

692 Aviation, Space, and Environmental Medicine x Vol. 81, No. 7 x July 2010
ATYPICAL TOOTH FRACTURE—GUNEPIN ET AL.
Additionally, the patient’s roommate stated that no grinding
noises were heard while the patient slept. The wear facets noted
in our examination were not on molar teeth. The cusps of his mo-
lar teeth were intact. So this phenomenon should not be the cause
of the tooth fracture in our pilot. We do recognize that many
fighter pilots do clench their teeth tightly together during anti-G
force abdominal straining actions in high G force dive pullouts.
• The patient stated that he never sustained any facial or dental
trauma before his tooth fractured.
Many authors assert that carious lesions are the main
etiology of high altitude dental fractures similar to the
two case reports described by Zadik et al. (13). Likewise
authors often conclude that dental breakage may be pre-
vented by regular dental examination and treatment
with adequate attention to existing dental restorations.
Our case report is not totally consistent with this point
of view because barometric pressure induced breakage
of teeth may occur on sound teeth in addition to teeth
with defective restorations or latent caries.
In fact, a review of the literature on odontocrexis left
us perplexed as regards the origin of the tooth fracture
that occurred in our pilot. In his writing, Sir Arthur
Conan Doyle’s famous character Sherlock Holmes said:
“When all but one hypothesis are eliminated, the last
one is, even if it is strongly improbable, the pure truth
(4).” This logic suggests that, in September 2009, our pa-
tient, after flying for many years in several types of air-
craft without any dental problems, was the victim of a
tooth fracture occurring on a sound tooth with no obvi-
ous predisposing factors.
Until now, odontocrexis was only described on teeth
with predisposing factors, i.e., pathology or large defec-
tive dental restorations. Through this case report, it ap-
pears that fractures may occur in a sound tooth under
hypobaric conditions. This observation leads us to con-
sider the limits of actual knowledge in aviation dentistry.
Only the sharing of knowledge between specialists in
aviation dentistry will enable us to understand the path-
ophysiology of these odontologic and pathologic phe-
nomena possibly due to changes in barometric pressure.
It is essential to understand these phenomena, their se-
quelae and prevention, since barondontalgia can inca-
pacitate a pilot and jeopardize flight safety, especially in
combat airspace such as Afghanistan.
Aviation, Space, and Environmental Medicine x Vol. 81, No. 7 x July 2010
ACKNOWLEDGMENT
Authors and affiliations: Mathieu Gunepin, D.D.S., Military School
of Artillery, Draguignan French Military Health Service, Draguignan
Cedex, France; Florence Derache, D.D.S., Military Hospital Sainte
Anne, Toulon French Military Health Service, Toulon Cedex, France;
and Thomas Audoual, M.D., Military Medical Center, Avord French
Military Health Service, Avord, France.
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